Reconstruction of chronic quadriceps tendon rupture using autologous semitendinosus tendon graft: A case report

Abstract

Introduction

Chronic quadriceps tendon rupture is a relatively rare injury that can be challenging to treat. Several techniques have been described for chronic quadriceps tendon repair, including the use of autografts, allografts, and synthetic mesh. We reported a case of 17-year-old male with chronic quadriceps tendon rupture treated using autologous semitendinosus tendon graft.

Case presentation

A 17-year-old male presented with left knee pain since 8 months ago after he fell into a ditch. Physical examination demonstrated palpable gap on suprapatellar region. Magnetic resonance imaging demonstrated quadriceps discontinuity and hyperintensity surrounding the insertion of the quadriceps tendon. The patient underwent quadriceps tendon reconstruction using ipsilateral autologous semitendinosus graft. After 3 weeks the patient was sent for physiotherapy to regain his left knee's range of motion. At final follow up at six months, the patient was able to walk with bipedal unassisted normal gait. Active knee extension and straight leg raising was possible. Final knee range of motion was 0° to 130°.

Discussion

In this case, we demonstrated a successfully treated chronic quadriceps tendon rupture using autologous semitendinosus tendon graft. For cases of chronic quadriceps tendon rupture with tissue loss, it is advisable to utilise an autologous graft for the purpose of repairing and restoring the structure and function of the quadriceps tendon.

Conclusion

Surgical treatment of chronic quadriceps tendon rupture is challenging and lacks evidence-based guidelines. We propose the use of ipsilateral semitendinosus tendon autograft as choice for chronic quadriceps tendon rupture in this report, as it leads to favorable outcomes postoperatively.

Highlights

• •Surgical treatment of chronic quadriceps tendon rupture is challenging and lacks evidence-based guidelines.
• •Various methods exist for chronic quadriceps tendon repair, such as the use of autografts, allografts, and synthetic mesh.
• •We successfully reconstruct chronic quadriceps tendon rupture using ipsilateral semitendinosus tendon autograft.

1. Introduction

Chronic quadriceps tendon rupture is a relatively rare injury that can be challenging to treat. While autologous tendon grafting is a widely accepted method, it is acknowledged that the process of harvesting tendons results in extended rehabilitation and heightened surgical complications, especially in older patients or those with pre-existing co-morbidities. The reconstruction of chronic quadriceps tendon injuries presents significant challenges and yields unsatisfactory results [1]. In this report, we reported a 17-year-old male with chronic quadriceps tendon rupture treated using ipsilateral semitendinosus graft and suture anchor to propose an option of surgical technique for quadriceps tendon reconstruction. This work has been reported in line with the SCARE criteria [2].

2. Case report

A 17-year-old male came to our institution with left knee pain since 8 months ago after he fell into a ditch. After the incident, the patient complained of left knee pain, especially when he tried to straighten his knee. Physical examination demonstrated palpable gap on suprapatellar region with reduced active range of motion. Pre-operative radiographic examinations showed no abnormalities apart from patella baja (Fig. 1), while magnetic resonance imaging demonstrated quadriceps discontinuity and hyperintensity surrounding the insertion of the quadriceps tendon (Fig. 2).

Fig. 1.

Preoperative X-ray demonstrated patella baja.

Fig. 2.

T2 magnetic resonance imaging of the left knee demonstrated quadriceps tendon discontinuity (1.5 cm) and hyperintensity surrounding the insertion of the quadriceps tendon.

On examination, there was a palpable gap on the suprapatellar region (Fig. 3A). Intraoperatively, we noticed huge defect of the quadriceps tendon that was surrounded by fibrotic tissues (Fig. 3B-D). We performed quadriceps tendon reconstruction using ipsilateral autologous semitendinosus graft. After incision, fibrotic tissue and scar adhesions around the quadriceps tendon are carefully excised to expose healthy tendon tissues. The remaining quadriceps tendon is evaluated for its quality and integrity. The semitendinosus tendon is harvested from the same leg through a separate incision typically made at the pes anserinus region. The harvested semitendinosus tendon is prepared appropriately, usually by removing excess soft tissue and creating a suitable size and thickness graft that matches the dimensions of the quadriceps tendon defect. The proximal part of the graft was fixed to the remnant of quadriceps tendon using the 5-0 Ethibond with Krackow suture technique. The distal part of the graft was fixed to the patella using double 5.5 mm metal suture anchors at the superior pole of patella. The postoperative Xray is shown in Fig. 4. Postoperatively, the patient was immobilized in backslab with his left knee in fully extended position. After 3 weeks the patient was sent for physiotherapy to regain his left knee's range of motion and muscle strengthening protocol. The passive and active knee's range of motion increased in increments every 2 weeks. At final follow up at six months, patient was able to walk with bipedal unassisted normal gait. Active knee extension and straight leg raising was possible. Final knee range of motion was from 0° to 130°.

Fig. 3.

Intraoperative process. (A) Palpable gap on the suprapatellar region; (B) huge defect surrounded by fibrotic tissues; (C) fixation of semitendinosus graft using suture anchor; (D) final reconstruction showed no palpable gap after the fixation.

Fig. 4.

Postoperative Xray of the right knee demonstrated double anchor fixations on the superior pole of the patella.

3. Discussion

The injury known as “chronic extensor mechanism quadriceps tendon rupture” is a severe condition that typically occurs when the rupture is not diagnosed in a timely manner, either owing to misdiagnosis or the incomplete rupture progressing to a complete rupture and seeking medical assistance at a later stage. Chronic rupture of a muscle will cause the muscle to contract, resulting in an expansion gap. The muscle body in this area becomes scarred, and the gap cannot be reduced. In addition, the quadriceps muscle experiences atrophy, leading to weakened quadriceps even after undergoing repair. This weakness, along with arthrofibrosis and residual stiffness, hinders the ability to attain the whole range of motion. Chronic quadriceps tendon ruptures present unique challenges for surgical repair due to tissue degeneration, scarring, and retraction that occur over time.

In this patient, we used semitendinosus muscle in the specific situation of Quadriceps Tendon Rupture (QTR). The patient achieved a good functional outcome postoperatively with no significant complaints. Various surgical methods can be employed to treat acute quadriceps tendon ruptures, including transosseous patellar tunnels, end-to-end sutures, anchor fixation, and graft augmentation. For cases of chronic quadriceps tendon rupture with tissue loss, it is advisable to utilise an autologous graft for the purpose of repairing and restoring the structure and function of the quadriceps tendon. McCormick et al. [3] performed a surgical intervention utilizing autografts from the patient's semitendinosus and gracilis tendons to repair and substitute injured tendons in instances of chronic quadriceps tendon rupture. The hamstring tendon transplant was threaded through the quadriceps tendon (QT) and went through three patellar tunnels, which were created by piercing the bone. Afterwards, the graft was secured and attached to the distal end of the patella. The semitendinosus graft is an autograft commonly employed in surgical procedures for anterior cruciate ligament (ACL) reconstruction. The semitendinosus tendon, in conjunction with the gracilis tendon, is extracted from the patient's own hamstring muscles and employed as a transplant to substitute the damaged ACL [4]. The semitendinosus tendon is folded to form a 4-stranded graft, resulting in a rigid biomechanical structure that is stiffer than other grafts including the patellar tendon, quadriceps tendon, and Achilles tendon grafts. A study by Janssen et al. [5] has shown the restoration of the mechanical characteristics of the hamstring tendons following ACL surgery using a semitendinosus tendon autograft. Quadriceps tendon rupture that is not treated promptly can result in unfavourable outcomes, such as decreased functional outcomes, worse satisfaction levels, and reduced isokinetic data in patients who have delayed repair. The choice of surgical technique depends on various factors, including the extent of tendon damage, patient factors, surgeon expertise, and available resources. A thorough preoperative evaluation and individualized treatment plan are essential to achieve optimal outcomes in patients with chronic quadriceps tendon ruptures. Postponing the surgical procedure can result in tendon shortening, scar tissue formation, and reduced blood circulation.

4. Conclusion

The surgical management of chronic quadriceps tendon rupture poses significant challenges and is currently lacking evidence-based guidelines. In this report, we suggest utilizing an ipsilateral semitendinosus tendon autograft as the preferred treatment for chronic quadriceps tendon rupture, as it results in positive outcomes after surgery.

Consent

Written informed consent was obtained from the patient's parents/legal guardian for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

Ethical approval was not required in in this case report.

Funding

The authors report no external source of funding during the writing of this article.

Author contribution

Ludwig Andribert Powantia Pontoh: Performed the surgery, wrote the manuscript.

Anissa Feby Canintika: Wrote the manuscript, provided scientific revisions to the manuscript.

Guarantor

Ludwig Andribert Powantia Pontoh is the sole guarantor of this submitted article.

Registration of research studies

Does not need any registration.

Conflict of interest statement

The authors declare no conflicts of interest.